P06.07 Learning Curve in Robotic-Assisted Thoracoscopic Pulmonary Resection: Experience of a Brazilian Surgeon

Abstract

The learning curve for robotic-assisted thoracoscopic (RATS) lung resection is yet to be defined, being suggested between 20 to 40 procedures to achieve proficiency. The generability of this data in Brazil is limited due to differences between publications’ methods and the Brazilian thoracic surgeon daily practice. The aim of this study is to determine how many resections are needed for proficiency in Brazil, comparing the patients’ characteristics and postoperative outcomes during the learning curve evolution. Retrospective study based in a prospective RATS database. We included patients who underwent anatomic lung resection performed by the main author between March 2015 and December 2020. Patients missing data regarding total duration of surgery and total console time were excluded. Scatterplots were used to determine the number of procedures to achieve proficiency. We divided the patients in tertiles, with the first one comprising the patients treated before proficiency, and the rest of them evenly distributed in the other tertiles. Subsequently we compared the groups regarding patients’ characteristics and postoperative outcomes. A total of 268 patients were included. The scatterplot revealed a learning curve of 20 procedures. There was no statistical difference regarding patients’ characteristics and outcomes between the groups, except for ASA classification (p<0.001). There was no mortality in 30 days in our study. Lobectomy was the main resection performed, with an increase without statistical significance in the complexity of resections. The total console time and total duration of surgery decreased across the learning curve (204 to 110 minutes, p<0.001 and 272.50 to 157 minutes, p<0.001, respectively),Table 1Patients characteristics and postoperative outcomesCharacteristics (268)1º tertile2º tertile3º tertilep valueFemale sex (n=268)6 (30.00)65 (52.00)70 (56.91)0.081Age (n=268)67.47 [58.06-71.18]65.72 [57.96-70.56]66.00 [59.00-72.00]0.817VEF1 (%) (n=181)81 [71-98]88 [78.5-97]88.5 [80-100]0.310Smoking history (n=257)15 (75.00)65 (54.62)55 (46.61)0.052CPOD (n=256)7 (35.00)18 (15.38)25 (21.01)0.106Hipertension (n=255)12 (60.00)56 (48.28)57 (47.90)0.591Cardiac disease (n=256)3 (15.00)18 (15.38)20 (16.81)0.949Diabetes (n=256)3 (15.00)17 (14.53)23 (16.80)0.600Renal disease (n=256)2 (10.00)4 (3.42)1 (0.84)0.056Diagnosis (n=252) Benign Adenocarcinoma Epidermoid Neuroendocrine tumor Pulmonary metastasis0 (0.00) 17 (85.00) 2 (10.00) 0 (0.00) 1 (5.00)7 (5.79) 88 (72.73) 7 (5.79) 12 (9.92) 7 (5.79)8 (7.21) 79 (71.17) 7 (6.31) 10 (9.01) 7 (6.31)0.817ASA (n=255) 1 2 313 (65.00) 6 (30.00) 1 (5.00)32 (27.83) 72 (62.61) 11 (9.57)18 (15.00) 92 (76.67) 10 (8.33)<0.001Pathological Staging 0 IA1 IA2 IA3 IB IIA IIB IIIA IIIB0 (0.00) 0 (0.00) 6 (31.58) 5 (26.32) 2 (10.53) 1 (5.26) 2 (10.53) 2 (10.53) 1 (5.26)7 (6.80) 20 (19.42) 32 (31.07) 14 (13.59) 11 (10.68) 0 (0.00) 6 (5.83) 10 (9.71) 3 (2.91)4 (5.33) 22 (29.33) 15 (20.00) 6 (8.00) 15 (20.00) 1 (1.33) 6 (8.00) 4 (5.33) 2 (2.67)0.098Resection (n=268) Lobectomy Lobectomy with bronchoplasty Segmentectomy Bilobectomy Pneumonectomy20 (100.00) 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00)93 (74.40) 3 (3.23) 31 (24.80) 1 (0.80) 0 (0.00)90 (73.17) 2 (2.22) 31 (25.20) 1 (0.81) 1 (0.81)0.236Number of lymph nodes evaluated (n=227)12 [7,5-14]11 [7-15]7.5 [6-11]0.001Number of stations evaluated (n=226)5 [4.5-6]6 [5-7]6 [5-7]0.082Total duration of surgery (n=268)272.50 [204.50-327.50]170 [130-205]157 [132-190]<0.001Total console time (n=268)204 [137.50-251.50]130 [90-160]110 [85-140]<0.001Days of chest tube drainage (n=255)2 [1-2]2 [1-3]1.5 [1-3]0.217Length of stay (n=254)3 [2-4]3 [2-5]3 [2-5]0.820Discharge with chest drainage (n=256)1 (5.00)7 (5.65)3 (2.68)0.485Complications (n=257)3 (15.00)26 (21.14)24 (20.62)0.892 Open table in a new tab Despite the differences in the daily practice, our learning curve was comparable to the literature, achieving proficiency after 20 lung resections. The group treated more recently presented higher functional limitation, however, the safety of the procedure was stable over time, with no increase in postoperative morbidity.